@article {11464, title = {The Influence of Cognitive Impairment on Post-Operative Outcomes.}, journal = {Annals of Surgery}, volume = {277}, year = {2023}, pages = {e212-e217}, abstract = {

OBJECTIVE: To examine differences in rates of elective surgery, postoperative mortality, and readmission by pre-existing cognitive status among Medicare beneficiaries undergoing surgery.

BACKGROUND: Mild cognitive impairment (MCI) is common among older adults, but the impact of MCI on surgical outcomes is understudied.

METHODS: We conducted a retrospective cohort study of individuals >=65 who underwent surgery between 2001 and 2015 using data from the nationally-representative Health and Retirement Study linked with Medicare claims. Cognitive status was assessed by the modified Telephone Interview for Cognitive Status score and categorized as normal cognition (score: 12-27), MCI (7-11), and dementia (<7). Outcomes were 30- and 90-day postoperative mortality and readmissions. We used Cox proportional hazard models to estimate the risk of each outcome by cognition, adjusting for patient characteristics.

RESULTS: In 6,590 patients, 69.9\% had normal cognition, 20.1\% had MCI, and 9.9\% had dementia. Patients with MCI (79.9\%) and dementia (73.6\%) were less likely to undergo elective surgery than patients with normal cognition (85.9\%). Patients with MCI had similar postoperative mortality and readmissions rates as patients with normal cognition. However, patients with dementia had significantly higher postoperative 90-day mortality (5.2\% vs. 8.4\%, p=0.002) and readmission rates (13.9\% vs. 17.3\%, p=0.038).

CONCLUSION: Patients with self-reported MCI are less likely to undergo elective surgery but have similar postoperative outcomes compared with patients with normal cognition. Despite the variability of defining MCI, our findings suggest that MCI may not confer additional risk for older individuals undergoing surgery, and should not be a barrier for surgical care.

}, keywords = {cognition impairment, Postoperative Period}, issn = {1528-1140}, doi = {10.1097/SLA.0000000000004799}, author = {Blair, Emilie M and Deborah A Levine and Hu, Hsou Mei and Kenneth M. Langa and Mohammed U Kabeto and Waljee, Jennifer} } @article {12060, title = {Validation of Claims Algorithms to Identify Alzheimer{\textquoteright}s Disease and Related Dementias.}, journal = {The Journals of Gerontology, Series A }, volume = {77}, year = {2022}, pages = {1261-1271}, abstract = {

BACKGROUND: Using billing data generated through healthcare delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

METHODS: We included 5,784 Medicare-enrolled, Health and Retirement Study participants aged >65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

RESULTS: Positive predictive value (PPV) of claims ranged from 53.8-70.3\% and was highest using a revised algorithm and 1-year of observation. The trade-off of greater PPV was lower sensitivity; sensitivity could be maximized using 3-years of observation. All algorithms had low sensitivity (31.3-56.8\%) and high specificity (92.3-98.0\%). Algorithm test performance varied by participant characteristics, including age and race.

CONCLUSIONS: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the trade-offs in accuracy among the approaches they consider.

}, keywords = {Accuracy, algorithm, Dementia, Diagnosis, Medicare}, issn = {1758-535X}, doi = {10.1093/gerona/glab373}, author = {Ellen P McCarthy and Chang, Chiang-Hua and Tilton, Nicholas and Mohammed U Kabeto and Kenneth M. Langa and Julie P W Bynum} } @article {11960, title = {Validation of self-reported cancer diagnoses using Medicare diagnostic claims in the U.S. Health and Retirement Study, 2000-2016.}, journal = {Cancer Epidemiology, Biomarkers \& Prevention}, volume = {31}, year = {2022}, pages = {287-292}, abstract = {

BACKGROUND: The US Health Retirement Study (HRS) is an ongoing population-representative cohort of US adults aged >50 with rich data on health during aging. Self-reported cancer diagnoses have been collected since 1998, but they have not been validated. We compared self-reported cancer diagnoses in HRS interviews against diagnostic claims from linked Medicare records.

METHODS: Using HRS-Medicare linked data, we examined the validity of first incident cancer diagnoses self-reported in biennial interviews from 2000-2016 against ICD-9 and ICD-10 diagnostic claim records as the gold standard. Data were from 8,242 HRS participants aged {greater than or equal to}65 with 90\% continuous enrollment in fee-for-service Medicare. We calculated the sensitivity, specificity, and k for first incident invasive cancer diagnoses (all cancers combined, and each of bladder, breast, colorectal/anal, uterine, kidney, lung, and prostate cancers) cumulatively over the follow-up and at each biennial study interview.

RESULTS: Overall, self-reports of first incident cancer diagnoses from 2000-2016 had 73.2\% sensitivity and 96.2\% specificity against Medicare claims (k=0.73). For specific cancer types, sensitivities ranged from 44.7\% (kidney) to 75.0\% (breast), and specificities ranged from 99.2\% (prostate) and 99.9\% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricting to individuals with 100\% continuous fee-for-service Medicare enrollment and when restricting to individuals with at least 24 months of Medicare enrollment.

CONCLUSION: Self-reported cancer diagnoses in the HRS have reasonable validity for use in population-based research that is maximized with linkage to Medicare.

IMPACT: These findings inform the use of the HRS for population-based cancer and aging research.

}, keywords = {cancer diagnoses, medicare diagnostic claims, Self-reported health}, issn = {1538-7755}, doi = {10.1158/1055-9965.EPI-21-0835}, author = {Megan Mullins and Jasdeep S Kler and Eastman, Marisa R and Mohammed U Kabeto and Lauren P Wallner and Lindsay C Kobayashi} } @article {11675, title = {The Effect of Childhood Socioeconomic Position and Social Mobility on Cognitive Function and Change Among Older Adults: A Comparison Between the United States and England.}, journal = {The Journals of Gerontology: Series B }, volume = {76}, year = {2021}, pages = {S51-S63}, abstract = {

OBJECTIVES: This study aims to examine the relationship between childhood socioeconomic position (SEP) and cognitive function in later life within nationally representative samples of older adults in the United States and England, investigate whether these effects are mediated by later-life SEP, and determine whether social mobility from childhood to adulthood affects cognitive function and decline.

METHOD: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Survey of Ageing (ELSA), we examined the relationships between measures of SEP, cognitive performance and decline using individual growth curve models.

RESULTS: High childhood SEP was associated with higher cognitive performance at baseline in both cohorts and did not affect the rate of decline. This benefit dissipated after adjusting for education and adult wealth in the United States. Respondents with low childhood SEP, above median education, and high adult SEP had better cognitive performance at baseline than respondents with a similar childhood background and less upward mobility in both countries.

DISCUSSION: These findings emphasize the impact of childhood SEP on cognitive trajectories among older adults. Upward mobility may partially compensate for disadvantage early in life but does not protect against cognitive decline.

}, keywords = {Cognition, Cross-national comparison, Early origins of health, Education, ELSA, Life course analysis}, issn = {1758-5368}, doi = {10.1093/geronb/gbaa138}, author = {Jessica Faul and Erin B Ware and Mohammed U Kabeto and Fisher, Jonah and Kenneth M. Langa} } @article {11486, title = {Unwelcome Companions: Loneliness Associates with the Cluster of Pain, Fatigue, and Depression in Older Adults}, journal = {Gerontology and Geriatric Medicine}, volume = {7}, year = {2021}, pages = {2333721421997620}, abstract = {Objective: Pain, fatigue, and depression commonly co-occur as a symptom cluster in pathological inflammatory states. Psychosocial stressors such as loneliness may lead to similar states through shared mechanisms. We investigated the association of loneliness with pain, fatigue, and depression in older adults. Methods: Using Health and Retirement Study data (N?=?11,766), we measured cross-sectional prevalence of frequent, moderate to severe pain; severe fatigue; depressive symptoms; and co-occurrence of symptoms surpassing threshold levels (i.e., symptom cluster). Logistic regression models evaluated associations with loneliness. Results: Pain, fatigue, and depression were reported in 19.2\%, 20.0\%, and 15.3\% of the total sample, respectively. The symptom cluster was seen in 4.9\% overall; prevalence in lonely individuals was significantly increased (11.6\% vs. 2.3\%, p?=65 with 90\% continuous enrollment in fee-for-service Medicare, using the claim records as the gold standard. We calculated the sensitivity, specificity, and k for first incident cancer diagnoses (all cancers combined, excluding non-melanoma skin cancer, and each of bladder, breast, colorectal/anal, uterine, kidney/renal, lung/bronchus, and prostate cancers) cumulatively over the follow-up, and at each biennial study interview. Results: Self-reports of first incident cancer diagnosis (agnostic of site) between 2000 and 2016 had 73.2\% sensitivity and 96.2\% specificity against Medicare claims (k = 0.73). For site-specific self-reports, sensitivities ranged from 44.7\% (kidney) to 75.0\% (breast), and specificities ranged from 99.2\% (prostate) to 99.9\% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricting to individuals with 100\% continuous fee-for-service Medicare enrollment and when restricting to individuals with at least 24 months of Medicare enrollment. Conclusions: Self-reported cancer diagnoses in the HRS have reasonable validity for population-based research on cancer and aging across cancer types. Apart from breast cancer, cancer site specific analyses will greatly benefit from the improved validity of self-report with Medicare claim linkage.}, keywords = {biomarker data, cancer diagnoses, Medicare, self-report}, doi = {10.1200/JCO.2020.39.28_suppl.312}, author = {Megan Mullins and Jasdeep S Kler and Eastman, Marissa and Mohammed U Kabeto and Lauren P Wallner and Lindsay C Kobayashi} } @article {11258, title = {Cardiovascular disease risk prediction for people with type 2 diabetes in a population-based cohort and in electronic health record data}, journal = {Jamia Open}, year = {2020}, abstract = {Electronic health records (EHRs) have become a common data source for clinical risk prediction, offering large sample sizes and frequently sampled metrics. There may be notable differences between hospital-based EHR and traditional cohort samples: EHR data often are not population-representative random samples, even for particular diseases, as they tend to be sicker with higher healthcare utilization, while cohort studies often sample healthier subjects who typically are more likely to participate. We investigate heterogeneities between EHR- and cohort-based inferences including incidence rates, risk factor identifications/quantifications, and absolute risks.This is a retrospective cohort study of older patients with type 2 diabetes using EHR from New York University Langone Health ambulatory care (NYULH-EHR, years 2009{\textendash}2017) and from the Health and Retirement Survey (HRS, 1995{\textendash}2014) to study subsequent cardiovascular disease (CVD) risks. We used the same eligibility criteria, outcome definitions, and demographic covariates/biomarkers in both datasets. We compared subsequent CVD incidence rates, hazard ratios (HRs) of risk factors, and discrimination/calibration performances of CVD risk scores.The estimated subsequent total CVD incidence rate was 37.5 and 90.6 per 1000 person-years since T2DM onset in HRS and NYULH-EHR respectively. HR estimates were comparable between the datasets for most demographic covariates/biomarkers. Common CVD risk scores underestimated observed total CVD risks in NYULH-EHR.EHR-estimated HRs of demographic and major clinical risk factors for CVD were mostly consistent with the estimates from a national cohort, despite high incidences and absolute risks of total CVD outcome in the EHR samples.}, keywords = {Cardiovascular disease, type 2 diabetes}, isbn = {2574-2531}, doi = {https://doi.org/10.1093/jamiaopen/ooaa059}, author = {Szymonifka, Jackie and Conderino, Sarah and Christine T Cigolle and Ha, Jinkyung and Mohammed U Kabeto and Yu, Jaehong and John A. Dodson and Thorpe, Lorna and Caroline S Blaum and Zhong, Judy} } @article {10968, title = {Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults}, journal = {Journal of Stroke and Cerebrovascular Diseases}, volume = {29}, year = {2020}, abstract = {Background and purpose Older patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition. Methods Prospective study of 591 adults >=65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7{\textendash}11) and normal cognition (score of 12{\textendash}27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3{\textendash}4). Results Among survivors of AIS, 26.9\% had pre-existing MCI (62.9\% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1\% had normal cognition (51.4\% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39\% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95\% CI, 0.43{\textendash}0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95\% CI, 0.56{\textendash}1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95\% CI, 0.95{\textendash}0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95\% CI, 0.31{\textendash}0.94]; P=0.03). Conclusions Differences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care.}, keywords = {Aging, cognitive impairment, Health policy/outcomes research, Ischemic stroke}, isbn = {1052-3057}, doi = {https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105083}, author = {Deborah A Levine and Andrzej T Galecki and Mohammed U Kabeto and Nallamothu, Brahmajee K. and Zahuranec, Darin B. and Lewis B Morgenstern and Lynda D Lisabeth and Bruno J Giordani and Kenneth M. Langa} } @article {10181, title = {Mild Cognitive Impairment and Receipt of Treatments for Acute Myocardial Infarction in Older Adults}, journal = {Journal of General Internal Medicine}, volume = {35}, year = {2020}, pages = {28{\textendash}35}, type = {Journal}, abstract = {Background Older adults with mild cognitive impairment (MCI) should receive evidence-based treatments when indicated. Providers and patients may overestimate the risk of dementia in patients with MCI leading to potential under-treatment. However, the association between pre-existing MCI and receipt of evidence-based treatments is uncertain. Objective To compare receipt of treatments for acute myocardial infarction (AMI) between older adults with pre-existing MCI and cognitively normal patients. Design Prospective study using data from the nationally representative Health and Retirement Study, Medicare, and American Hospital Association. Participants Six hundred nine adults aged 65 or older hospitalized for AMI between 2000 and 2011 and followed through 2012 with pre-existing MCI (defined as modified Telephone Interview for Cognitive Status score of 7{\textendash}11) and normal cognition (score of 12{\textendash}27). Main Measures Receipt of cardiac catheterization and coronary revascularization within 30 days and cardiac rehabilitation within 1 year of AMI hospitalization. Key Results Among the survivors of AMI, 19.2\% had pre-existing MCI (55.6\% were women and 44.4\% were male, with a mean [SD] age of 82.3 [7.5] years), and 80.8\% had normal cognition (45.7\% were women and 54.3\% were male, with a mean age of 77.1 [7.1] years). Survivors of AMI with pre-existing MCI were significantly less likely than those with normal cognition to receive cardiac catheterization (50\% vs 77\%; P < 0.001), coronary revascularization (29\% vs 63\%; P < 0.001), and cardiac rehabilitation (9\% vs 22\%; P = 0.001) after AMI. After adjusting for patient and hospital factors, pre-existing MCI remained associated with lower use of cardiac catheterization (adjusted hazard ratio (aHR), 0.65; 95\% CI, 0.48{\textendash}0.89; P = 0.007) and coronary revascularization (aHR, 0.55; 95\% CI, 0.37{\textendash}0.81; P = .003), but not cardiac rehabilitation (aHR, 1.01; 95\% CI, 0.49{\textendash}2.07; P = 0.98). Conclusions Pre-existing MCI is associated with lower use of cardiac catheterization and coronary revascularization but not cardiac rehabilitation after AMI.}, keywords = {Cognitive Ability, Heart disease, Medicare/Medicaid/Health Insurance}, issn = {0884-8734}, doi = {10.1007/s11606-019-05155-8}, url = {https://link.springer.com/article/10.1007\%2Fs11606-019-05155-8$\#$citeas}, author = {Deborah A Levine and Kenneth M. Langa and Andrzej T Galecki and Mohammed U Kabeto and Lewis B Morgenstern and Zahuranec, Darin B. and Bruno J Giordani and Lynda D Lisabeth and Nallamothu, Brahmajee K.} } @article {10155, title = {Multimorbidity and cognitive decline over 14 years in older Americans.}, journal = {Journals of Gerontology. Series A, Biological Sciences \& Medical Sciences}, year = {2020}, abstract = {

BACKGROUND: Multimorbidity is associated with greater disability and accelerated declines in physical functioning over time in older adults. However, less is known about its effect on cognitive decline.

METHODS: Participants without dementia from the Health and Retirement Study were interviewed about physician-diagnosed conditions, from which their multimorbidity-weighted index (MWI) that weights diseases to physical functioning was computed. We used linear mixed-effects models to examine the predictor MWI with the modified Telephone Interview for Cognitive Status (TICSm, global cognition), 10-word immediate recall and delayed recall, and serial 7s outcomes biennially after adjusting for baseline cognition and covariates.

RESULTS: 14,265 participants, 60\% female, contributed 73,700 observations. Participants had a meanSD age 679.3 years and MWI 4.43.9 at baseline. Each point increase in MWI was associated with declines in global cognition (0.04, 95\%CI: 0.03-0.04 TICSm), immediate recall (0.01, 95\%CI: 0.01-0.02 words), delayed recall (0.01, 95\%CI: 0.01-0.02 words), and working memory (0.01, 95\%CI: 0.01-0.02 serial 7s) (all P<0.001). Multimorbidity was associated with faster declines in global cognition (0.003 points/year faster, 95\%CI: 0.002-0.004), immediate recall (0.001 words/year faster, 95\%CI: 0.001-0.002), and working memory (0.006 incorrect serial 7s/year faster, 95\%CI: 0.004-0.009) (all P<0.001), but not delayed recall compared with premorbid slopes.

CONCLUSIONS: Multimorbidity using a validated index weighted to physical functioning was associated with acute decline in cognition and accelerated and persistent cognitive decline over 14 years. This study supports an ongoing geriatric syndrome of coexisting physical and cognitive impairment in adults with multimorbidity. Clinicians should monitor and address both domains in older multimorbid adults.

}, keywords = {Cognitive Ability, Comorbidity, Longitudinal data}, issn = {1758-535X}, doi = {10.1093/gerona/glz147}, author = {Melissa Y Wei and Deborah A Levine and Laura B Zahodne and Mohammed U Kabeto and Kenneth M. Langa} } @article {9548, title = {Physical Functioning Decline and Mortality in Older Adults with Multimorbidity: Joint Modeling of Longitudinal and Survival Data.}, journal = {Journals of Gerontology Series A: Biological Sciences \& Medical Sciences}, volume = {74}, year = {2019}, pages = {226-232}, abstract = {

Background: Multimorbidity is common among older adults and strongly associated with physical functioning decline and increased mortality. However, the full spectrum of direct and indirect effects of multimorbidity on physical functioning and survival has not been quantified. We aimed to determine the longitudinal relationship of multimorbidity on physical functioning and quantify the impact of multimorbidity and multimorbidity-attributed changes in physical functioning on mortality risk.

Methods: The Health and Retirement Study is a nationally-representative population-based prospective cohort of adults aged 51 or older. In 2000, participants were interviewed about physician-diagnosed chronic conditions, from which their multimorbidity-weighted index (MWI) was computed. Between 2000-2011, participants reported their current physical functioning using a modified Short Form-36. With MWI as a time-varying exposure, we jointly modeled its associations with physical functioning and survival.

Results: The final sample included 74,037 observations from 18,174 participants. At baseline, participants had a weighted mean MWI of 4.64.2 (range 0-36.8). During follow-up, physical functioning declined -1.72~(95\% CI:~-1.77, -1.67, p<0.001) HRS physical functioning units per point MWI in adjusted models. Over follow-up, 6,362 (34\%) participants died. Mortality risk increased 8\% (HR 1.08, 95\% CI 1.07-1.08, p<0.001) per point MWI in adjusted models. Across all population subgroups, MWI was associated with greater physical functioning decline and mortality risk.

Conclusions: Multimorbidity and its associated decline in physical functioning were significantly associated with increased mortality. These associations can be predicted with an easily interpreted and applied multimorbidity index that can better identify and target adults at increased risk for disability and death.

}, keywords = {Comorbidity, Mortality, Physical Ability}, issn = {1758-535X}, doi = {10.1093/gerona/gly038}, author = {Melissa Y Wei and Mohammed U Kabeto and Andrzej T Galecki and Kenneth M. Langa} } @article {9158, title = {Multimorbidity and physical and cognitive function: performance of a new multimorbidity-weighted index.}, journal = {Journals of Gerontology Series A: Biological Sciences \& Medical Sciences}, volume = {73}, year = {2018}, pages = {225}, abstract = {

Background: Multimorbidity is an important health outcome but is difficult to quantify. We recently developed a multimorbidity-weighted index (MWI) and herein assess its performance in an independent nationally-representative cohort.

Methods: Health and Retirement Study (HRS) participants completed an interview on physician-diagnosed chronic conditions and physical functioning. We determined the relationship of chronic conditions on physical functioning and validated these weights with the original, independently-derived MWI. We then determined the association between MWI with physical functioning, grip strength, gait speed, basic and instrumental activities of daily living (ADL/IADL) limitations, and the modified Telephone Interview for Cognitive Status (TICS-m) in adjusted models.

Results: Among 20,509 adults, associations between chronic conditions and physical functioning varied several-fold. MWI values based on weightings in the HRS and original cohorts correlated strongly (Pearson{\textquoteright}s r=0.92) and had high classification agreement (Kappa statistic=0.80, p<0.0001). Participants in the highest vs. lowest MWI quartiles had weaker grip strength (-2.91 kg, 95\%CI: -3.51, -2.30), slower gait speed (-0.29 m/s, 95\%CI: -0.35, -0.23), more ADL (0.79, 95\%CI: 0.71, 0.87) and IADL (0.49, 95\%CI: 0.44, 0.55) limitations, and lower TICS-m (-0.59, 95\%CI: -0.77, -0.41) (all P<0.001). We observed monotonic graded relationships for all outcomes with increasing MWI quartiles.

Conclusion: A multimorbidity index weighted to physical functioning performed nearly identically in a nationally-representative cohort as it did in its development cohorts, confirming broad generalizability. MWI was strongly associated with subjective and objective physical and cognitive performance. Thus, MWI serves as a valid patient-centered measure of multimorbidity, an important construct in research and clinical practice.

}, keywords = {Cognition \& Reasoning, Comorbidity}, issn = {1758-535X}, doi = {10.1093/gerona/glx114}, author = {Melissa Y Wei and Mohammed U Kabeto and Kenneth M. Langa and Kenneth J Mukamal} } @article {9391, title = {Secular Trends in Dementia and Cognitive Impairment of U.S. Rural and Urban Older Adults}, journal = {American Journal of Preventive Medicine}, volume = {54}, year = {2018}, pages = {164-172}, abstract = {Introduction This is a nationally representative study of rural-urban disparities in the prevalence of probable dementia and cognitive impairment without dementia (CIND). Methods Data on non-institutionalized U.S. adults from the 2000 (n=16,386) and 2010 (n=16,311) cross-sections of the Health and Retirement Study were linked to respective Census assessments of the urban composition of residential census tracts. Relative risk ratios (RRR) for rural-urban differentials in dementia and CIND respective to normal cognitive status were assessed using multinomial logistic regression. Analyses were conducted in 2016. Results Unadjusted prevalence of dementia and CIND in rural and urban tracts converged so that rural disadvantages in the relative risk of dementia (RRR=1.42, 95\% CI=1.10, 1.83) and CIND (RRR=1.35, 95\% CI=1.13, 1.61) in 2000 no longer reached statistical significance in 2010. Adjustment for the strong protective role of educational attainment reduced rural disadvantages in 2000 to statistical nonsignificance, whereas adjustment for race/ethnicity resulted in a statistically significant increase in RRRs in 2010. Full adjustment for sociodemographic and health factors revealed persisting rural disadvantages for dementia and CIND in both periods with RRR in 2010 for dementia of 1.79 (95\% CI=1.31, 2.43) and for CIND of 1.38 (95\% CI=1.14, 1.68). Conclusions Larger gains in rural adults{\textquoteright} cognitive functioning between 2000 and 2010 that are linked with increased educational attainment demonstrate long-term public health benefits of investment in secondary education. Persistent disadvantages in cognitive functioning among rural adults compared with sociodemographically similar urban peers highlight the importance of public health planning for more rapidly aging rural communities.}, keywords = {Cognitive Ability, Dementia, Religion, Rural Settings, urban life}, issn = {07493797}, doi = {10.1016/j.amepre.2017.10.021}, url = {http://linkinghub.elsevier.com/retrieve/pii/S074937971730644Xhttp://api.elsevier.com/content/article/PII:S074937971730644X?httpAccept=text/xmlhttp://api.elsevier.com/content/article/PII:S074937971730644X?httpAccept=text/plain}, author = {Margaret M Weden and Regina A Shih and Mohammed U Kabeto and Kenneth M. Langa} } @article {9280, title = {Association between spousal caregiver well-being and care recipient healthcare expenditures}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {2220-2226}, abstract = {Objectives To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use. Design Prospective cohort study. Setting Health and Retirement Study. Participants Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101). Exposure Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures. Measurements Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months. Results Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment (P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95\% confidence interval (CI) = $770{\textendash}3,105) and caregiver sadness (cost increase, $1,323, 95\% CI = $228{\textendash}2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment (P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio (OR) = 1.24, 95\% CI = 1.01{\textendash}1.52) and caregiver fair to poor health (OR = 1.23, 95\% CI = 1.04{\textendash}1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes. Conclusion Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use.}, keywords = {Caregiving, Marriage, Medical Expenses, Medicare/Medicaid/Health Insurance, Well-being}, doi = {10.1111/jgs.15039}, url = {http://doi.wiley.com/10.1111/jgs.15039http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15039/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111\%2Fjgs.15039}, author = {Claire K. Ankuda and Donovan T Maust and Mohammed U Kabeto and Ryan J McCammon and Kenneth M. Langa and Deborah A Levine} } @article {8813, title = {A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012.}, journal = {JAMA Intern Med}, volume = {177}, year = {2017}, month = {2017 01 01}, pages = {51-58}, abstract = {

Importance: The aging of the US population is expected to lead to a large increase in the number of adults with dementia, but some recent studies in the United States and other high-income countries suggest that the age-specific risk of dementia may have declined over the past 25 years. Clarifying current and future population trends in dementia prevalence and risk has important implications for patients, families, and government programs.

Objective: To compare the prevalence of dementia in the United States in 2000 and 2012.

Design, Setting, and Participants: We used data from the Health and Retirement Study (HRS), a nationally representative, population-based longitudinal survey of individuals in the United States 65 years or older from the 2000 (n = 10 546) and 2012 (n = 10 511) waves of the HRS.

Main Outcomes and Measures: Dementia was identified in each year using HRS cognitive measures and validated methods for classifying self-respondents, as well as those represented by a proxy. Logistic regression was used to identify socioeconomic and health variables associated with change in dementia prevalence between 2000 and 2012.

Results: The study cohorts had an average age of 75.0 years (95\% CI, 74.8-75.2 years) in 2000 and 74.8 years (95\% CI, 74.5-75.1 years) in 2012 (P = .24); 58.4\% (95\% CI, 57.3\%-59.4\%) of the 2000 cohort was female compared with 56.3\% (95\% CI, 55.5\%-57.0\%) of the 2012 cohort (P < .001). Dementia prevalence among those 65 years or older decreased from 11.6\% (95\% CI, 10.7\%-12.7\%) in 2000 to 8.8\% (95\% CI, 8.2\%-9.4\%) (8.6\% with age- and sex-standardization) in 2012 (P < .001). More years of education was associated with a lower risk for dementia, and average years of education increased significantly (from 11.8 years [95\% CI, 11.6-11.9 years] to 12.7 years [95\% CI, 12.6-12.9 years]; P < .001) between 2000 and 2012. The decline in dementia prevalence occurred even though there was a significant age- and sex-adjusted increase between years in the cardiovascular risk profile (eg, prevalence of hypertension, diabetes, and obesity) among older US adults.

Conclusions and Relevance: The prevalence of dementia in the United States declined significantly between 2000 and 2012. An increase in educational attainment was associated with some of the decline in dementia prevalence, but the full set of social, behavioral, and medical factors contributing to the decline is still uncertain. Continued monitoring of trends in dementia incidence and prevalence will be important for better gauging the full future societal impact of dementia as the number of older adults increases in the decades ahead.

}, keywords = {Aged, Dementia, Female, Humans, Male, Prevalence, Risk Factors, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2016.6807}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.6807http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587084}, author = {Kenneth M. Langa and Eric B Larson and Eileen M. Crimmins and Jessica Faul and Deborah A Levine and Mohammed U Kabeto and David R Weir} } @article {8542, title = {Lagged Associations of Metropolitan Statistical Area- and State-Level Income Inequality with Cognitive Function: The Health and Retirement Study.}, journal = {PLoS One}, volume = {11}, year = {2016}, month = {2016}, pages = {e0157327}, abstract = {

PURPOSE: Much variation in individual-level cognitive function in late life remains unexplained, with little exploration of area-level/contextual factors to date. Income inequality is a contextual factor that may plausibly influence cognitive function.

METHODS: In a nationally-representative cohort of older Americans from the Health and Retirement Study, we examined state- and metropolitan statistical area (MSA)-level income inequality as predictors of individual-level cognitive function measured by the 27-point Telephone Interview for Cognitive Status (TICS-m) scale. We modeled latency periods of 8-20 years, and controlled for state-/metropolitan statistical area (MSA)-level and individual-level factors.

RESULTS: Higher MSA-level income inequality predicted lower cognitive function 16-18 years later. Using a 16-year lag, living in a MSA in the highest income inequality quartile predicted a 0.9-point lower TICS-m score (β = -0.86; 95\% CI = -1.41, -0.31), roughly equivalent to the magnitude associated with five years of aging. We observed no associations for state-level income inequality. The findings were robust to sensitivity analyses using propensity score methods.

CONCLUSIONS: Among older Americans, MSA-level income inequality appears to influence cognitive function nearly two decades later. Policies reducing income inequality levels within cities may help address the growing burden of declining cognitive function among older populations within the United States.

}, keywords = {Cities, Cognition, Female, health, Humans, Income, Interviews as Topic, Linear Models, Male, Middle Aged, Multivariate Analysis, Residence Characteristics, Retirement, Socioeconomic factors, Statistics as Topic, Telephone, United States}, issn = {1932-6203}, doi = {10.1371/journal.pone.0157327}, url = {http://dx.doi.org/10.1371/journal.pone.0157327}, author = {Kim, Daniel and Griffin, Beth Ann and Mohammed U Kabeto and Jos{\'e} J Escarce and Kenneth M. Langa and Regina A Shih}, editor = {M. Maria Glymour} } @article {8289, title = {Does Stroke Contribute to Racial Differences in Cognitive Decline?}, journal = {Stroke}, volume = {46}, year = {2015}, month = {2015 Jul}, pages = {1897-902}, publisher = {46}, abstract = {

BACKGROUND AND PURPOSE: It is unknown whether blacks{\textquoteright} elevated risk of dementia is because of racial differences in acute stroke, the impact of stroke on cognitive health, or other factors. We investigated whether racial differences in cognitive decline are explained by differences in the frequency or impact of incident stroke between blacks and whites, controlling for baseline cognition.

METHODS: Among 4908 black and white participants aged >=65 years free of stroke and cognitive impairment in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we examined longitudinal changes in global cognition (modified version of the Telephone Interview for Cognitive Status) by race, before and after adjusting for time-dependent incident stroke followed by a race-by-incident stroke interaction term, using linear mixed-effects models that included fixed effects of participant demographics, clinical factors, and cognition, and random effects for intercept and slope for time.

RESULTS: We identified 34 of 453 (7.5\%) blacks and 300 of 4455 (6.7\%) whites with incident stroke over a mean (SD) of 4.1 (1.9) years of follow-up (P=0.53). Blacks had greater cognitive decline than whites (adjusted difference in modified version of the Telephone Interview for Cognitive Status score, 1.47 points; 95\% confidence interval, 1.21 to 1.73 points). With further adjustment for cumulative incidence of stroke, the black-white difference in cognitive decline persisted. Incident stroke was associated with a decrease in global cognition (1.21 points; P<0.001) corresponding to ≈7.9 years of cognitive aging. The effect of incident stroke on cognition did not statistically differ by race (P=0.52).

CONCLUSIONS: In this population-based cohort of older adults, incident stroke did not explain black-white differences in cognitive decline or impact cognition differently by race.

}, keywords = {African Continental Ancestry Group, Aged, Aged, 80 and over, Cognition Disorders, European Continental Ancestry Group, Female, Humans, Longitudinal Studies, Male, Risk Factors, Stroke}, issn = {1524-4628}, doi = {10.1161/STROKEAHA.114.008156}, url = {http://stroke.ahajournals.org/content/early/2015/05/20/STROKEAHA.114.008156.abstract}, author = {Deborah A Levine and Mohammed U Kabeto and Kenneth M. Langa and Lynda D Lisabeth and Mary A M Rogers and Andrzej T Galecki} } @article {8660, title = {Factors associated with cognitive evaluations in the United States.}, journal = {Neurology}, volume = {84}, year = {2015}, month = {2015 Jan 06}, pages = {64-71}, abstract = {

OBJECTIVE: We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States.

METHODS: Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression.

RESULTS: Of the 297 participants with dementia in ADAMS, 55.2\% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95\% confidence interval: 1.10-6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia.

CONCLUSIONS: Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Cohort Studies, Dementia, Female, Humans, Logistic Models, Male, Marital Status, Multivariate Analysis, Neuropsychological tests, Severity of Illness Index, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001096}, url = {http://www.neurology.org/cgi/doi/10.1212/WNL.0000000000001096}, author = {Vikas Kotagal and Kenneth M. Langa and Brenda L Plassman and Gwenith G Fisher and Bruno J Giordani and Robert B Wallace and James F. Burke and David C Steffens and Mohammed U Kabeto and Roger L. Albin and Norman L Foster} } @article {7713, title = {Antigenic challenge in the etiology of autoimmune disease in women.}, journal = {J Autoimmun}, volume = {38}, year = {2012}, note = {Rogers, Mary A M Levine, Deborah A Blumberg, Neil Fisher, Gwenith G Kabeto, Mohammed Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ HL078603/HL/NHLBI NIH HHS/ HL095467/HL/NHLBI NIH HHS/ HL100051/HL/NHLBI NIH HHS/ R21 HL093129-01A1/HL/NHLBI NIH HHS/ R21 HL093129-02/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ England J Autoimmun. 2012 May;38(2-3):J97-J102. Epub 2011 Aug 30.}, month = {2012 May}, pages = {J97-J102}, publisher = {38}, abstract = {

Infection has long been implicated as a trigger for autoimmune disease. Other antigenic challenges include receipt of allogeneic tissue or blood resulting in immunomodulation. We investigated antigenic challenges as possible risk factors for autoimmune disease in women using the Health and Retirement Study, a nationally representative longitudinal study, linked to Medicare files, years 1991-2007. The prevalence of autoimmune disease (rheumatoid arthritis, Hashimoto{\textquoteright}s disease, Graves{\textquoteright} disease, systemic lupus erythematosus, celiac disease, systemic sclerosis, Sj{\"o}gren syndrome and multiple sclerosis) was 1.4\% in older women (95\% CI: 1.3\%, 1.5\%) with significant variation across regions of the United States. The risk of autoimmune disease increased by 41\% (95\% CI of incidence rate ratio (IRR): 1.10, 1.81) with a prior infection-related medical visit. The risk of autoimmune disease increased by 90\% (95\% CI of IRR: 1.36, 2.66) with a prior transfusion without infection. Parity was not associated with autoimmune disease. Women less than 65 years of age and Jewish women had significantly elevated risk of developing autoimmune disease, as did individuals with a history of heart disease or end-stage renal disease. Antigenic challenges, such as infection and allogeneic blood transfusion, are significant risk factors for the development of autoimmune disease in older women.

}, keywords = {Aged, Aged, 80 and over, Antigens, Autoimmune Diseases, Female, Humans, Incidence, Middle Aged, Prevalence, Risk Factors, United States}, issn = {1095-9157}, doi = {10.1016/j.jaut.2011.08.001}, author = {Mary A M Rogers and Deborah A Levine and Neil Blumberg and Gwenith G Fisher and Mohammed U Kabeto and Kenneth M. Langa} } @article {7775, title = {Clinical complexity and mortality in middle-aged and older adults with diabetes.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {67}, year = {2012}, month = {2012 Dec}, pages = {1313-20}, publisher = {67}, abstract = {

BACKGROUND: Middle-aged and older adults with diabetes are heterogeneous and may be characterized as belonging to one of three clinical groups: a relatively healthy group, a group having characteristics likely to make diabetes self-management difficult, and a group with poor health status for whom current management targets have uncertain benefit.

METHODS: We analyzed waves 2004-2008 of the Health and Retirement Study and the supplemental Health and Retirement Study 2003 Diabetes Study. The sample included adults with diabetes 51 years and older (n = 3,507, representing 13.6 million in 2004). We investigated the mortality outcomes for the three clinical groups, using survival analysis and Cox proportional hazard models.

RESULTS: The 5-year survival probabilities were Relatively Healthy Group, 90.8\%; Self-Management Difficulty Group, 79.4\%; and Uncertain Benefit Group, 52.5\%. For all age groups and clinical groups, except those 76 years and older in the Uncertain Benefit Group, survival exceeded 50\%.

CONCLUSIONS: This study reveals the substantial survival of middle-aged and older adults with diabetes, regardless of health status. These findings have implications for the clinical management of and future research about diabetes patients with multiple comorbidities.

}, keywords = {Activities of Daily Living, Aged, Comorbidity, Diabetes Complications, Diabetes Mellitus, Female, Health Status, Humans, Male, Middle Aged, Proportional Hazards Models, Self Care}, issn = {1758-535X}, doi = {10.1093/gerona/gls095}, author = {Christine T Cigolle and Mohammed U Kabeto and Pearl G. Lee and Caroline S Blaum} } @article {7530, title = {The case for involving adult children outside of the household in the self-management support of older adults with chronic illnesses.}, journal = {Chronic Illn}, volume = {6}, year = {2010}, month = {2010 Mar}, pages = {34-45}, publisher = {6}, abstract = {

OBJECTIVES: This study sought to (1) identify barriers to spousal support for chronic illness self-care among community-dwelling older adults; and (2) describe the potential availability of self-care support from adult children living outside of the household.

METHODS: Nationally representative US sample of chronically ill adults aged 51+ were interviewed as part of the Health and Retirement Study (N = 14,862). Both participants and their spouses (when available) reported information about their health and functioning. Participants also reported information about their contact with adult children and the quality of those relationships.

RESULTS: More than one-third (38\%) of chronically ill older adults in the US are unmarried; and when spouses are available, the majority of them have multiple chronic diseases and functional limitations. However, the vast majority of chronically ill older adults (93\%, representing roughly 60 million Americans) have adult children, with half having children living over 10 miles away. Most respondents with children (78\%) reported at least weekly telephone contact and that these relationships were positive. Roughly 19 million older chronically ill Americans have adult children living at a distance but none nearby; these children are in frequent telephone contact and respondents (including those with multiple chronic diseases) report that the relationships are positive.

DISCUSSION: As the gap between available health services for disease management and the need among community-dwelling patients continues to grow, adult children-including those living at a distance-represent an important resource for improving self-care support for people with chronic diseases.

}, keywords = {Adult, Chronic disease, Family Relations, Female, Humans, Male, Middle Aged, Self Care, Social Support}, issn = {1745-9206}, doi = {10.1177/1742395309347804}, author = {John D Piette and Ann Marie Rosland and Maria J Silveira and Mohammed U Kabeto and Kenneth M. Langa} } @article {7531, title = {Depression among older adults in the United States and England.}, journal = {Am J Geriatr Psychiatry}, volume = {18}, year = {2010}, month = {2010 Nov}, pages = {1036-44}, publisher = {11}, abstract = {

CONTEXT: Depression negatively affects health and well being among older adults, but there have been no nationally representative comparisons of depression prevalence among older adults in England and the United States.

OBJECTIVE: The authors sought to compare depressive symptoms among older adults in these countries and identify sociodemographic and clinical correlates of depression in these countries.

DESIGN AND SETTING: The authors assessed depressive symptoms in non-Hispanic whites aged 65 years and older in 2002 in two nationally representative, population-based studies: the U.S. Health and Retirement Study and English Longitudinal Study of Ageing.

PARTICIPANTS: A total of 8,295 Health and Retirement Study respondents and 5,208 English Longitudinal Study of Ageing respondents.

MAIN OUTCOME MEASURES: The authors measured depressive symptoms using the eight-item Center for Epidemiologic Studies Depression Scale. The authors determined whether depressive symptom differences between the United States and England were associated with sociodemographic characteristics, chronic health conditions, and health behaviors.

RESULTS: Significant depressive symptoms (Center for Epidemiologic Studies Depression Scale score >=4) were more prevalent in English than U.S. adults (17.6\% versus 14.6\%, adjusted Wald test F([1, 1593]) = 11.4, p < 0.001). Adjusted rates of depressive symptoms in England were 19\% higher compared with the United States (odds ratio: 1.19, 95\% confidence interval: 1.01-1.40). U.S. adults had higher levels of education, and net worth, but lower levels of activities of daily living/instrumental activities of daily living impairments, tobacco use, and cognitive impairment, which may have contributed to relatively lower levels of depressive symptoms in the United States.

CONCLUSIONS: Older adults in the United States had lower rates of depressive symptoms than their English counterparts despite having more chronic health conditions. Future cross-national studies should identify how depression treatment influences outcomes in these populations.

}, keywords = {Aged, Aged, 80 and over, depression, England, Female, Health Behavior, Health Status, Health Surveys, Humans, Male, Prevalence, Risk Factors, United States, White People}, issn = {1545-7214}, doi = {10.1097/JGP.0b013e3181dba6d2}, author = {Zivin, Kara and David J Llewellyn and Iain A Lang and Sandeep Vijan and Mohammed U Kabeto and Erin M Miller and Kenneth M. Langa} } @article {7464, title = {Differences in functional impairment across subtypes of dementia.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {65}, year = {2010}, month = {2010 Apr}, pages = {434-41}, publisher = {65A}, abstract = {

BACKGROUND: Dementia is a cause of disability in later life. Despite the importance of functional status to the diagnosis of dementia, limited information exists on differences in functional limitations by dementia subtype. We conducted a cross-sectional analysis using the Aging, Demographics, and Memory Study (ADAMS) to determine the extent of functional impairment among older adults with dementia due to different etiologies.

METHODS: The ADAMS sample consisted of 856 individuals aged 71 years and older originally surveyed as part of the Health and Retirement Study. Based on a comprehensive in-person cognitive evaluation, respondents were assigned to diagnostic categories of normal cognition, cognitive impairment not demented, and demented. Dementia subtypes were grouped into three categories: vascular dementia (VaD), Alzheimer{\textquoteright}s dementia (AD), and dementia due to other etiologies. For 744 of the 856 respondents, a proxy informant completed a questionnaire asking whether the respondent had difficulty completing instrumental activities of daily living and activities of daily living (ADLs).

RESULTS: Of 744 ADAMS participants, 263 had dementia: 199 (70.5\%) with AD, 42 (16.9\%) with VaD, and 22 (12.6\%) were demented due to other etiologies. After adjustment for demographics, chronic illnesses, and dementia severity, participants with VaD (odds ratio [OR] 5.74; 95\% confidence interval [CI] 2.60-12.69) and other etiologies of dementia (OR 21.23; 95\% CI 7.25-62.16) were more likely to have greater than or equal to four ADL limitations compared with those with AD.

CONCLUSIONS: VaD is associated with significantly more ADL limitations than AD. These physical limitations should be considered when designing adult day care programs, which adequately accommodate the needs of non-AD patients.

}, keywords = {Activities of Daily Living, Aged, Alzheimer disease, Dementia, Dementia, Vascular, Humans}, issn = {1758-535X}, doi = {10.1093/gerona/glp197}, author = {Tanya R Gure and Mohammed U Kabeto and Brenda L Plassman and John D Piette and Kenneth M. Langa} } @article {7450, title = {Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.}, journal = {Med Care}, volume = {48}, year = {2010}, note = {Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus}, month = {2010 Feb}, pages = {87-94}, publisher = {48}, abstract = {

CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47\% compared with 38\%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54\% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42\% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

}, keywords = {Aged, Aged, 80 and over, Cardiovascular Diseases, Female, Financing, Personal, Health Care Costs, Health Services Accessibility, Health Status Disparities, Hospitalization, Humans, Logistic Models, Longitudinal Studies, Male, Medication Adherence, Middle Aged, Multivariate Analysis, Risk Factors, United States}, issn = {1537-1948}, doi = {10.1097/MLR.0b013e3181c12e53}, author = {Michele M Heisler and Choi, Hwajung and Allison B Rosen and Sandeep Vijan and Mohammed U Kabeto and Kenneth M. Langa and John D Piette} } @article {7524, title = {Vascular health, diabetes, APOE and dementia: the Aging, Demographics, and Memory Study.}, journal = {Alzheimers Res Ther}, volume = {2}, year = {2010}, month = {2010 Jun 24}, pages = {19}, publisher = {2}, abstract = {

INTRODUCTION: Evidence from clinical samples and geographically limited population studies suggests that vascular health, diabetes and apolipoprotein epsilon4 (APOE) are associated with dementia.

METHODS: A population-based sample of 856 individuals aged 71 years or older from all contiguous regions of the United States received an extensive in-home clinical and neuropsychological assessment in 2001-2003. The relation of hypertension, diabetes, heart disease, stroke, medication usage, and APOE epsilon4 to dementia was modelled using adjusted multivariable logistic regression.

RESULTS: Treated stroke (odds ratio [OR] 3.8, 95\% confidence interval [CI] 2.0, 7.2), untreated stroke (OR 3.5, 95\% CI 1.7, 7.3), and APOE epsilon4 (OR 2.8, 95\% CI 1.7, 4.5) all increased the odds of dementia. Treated hypertension was associated with lower odds of dementia (OR 0.5, 95\% CI 0.3, 1.0). Diabetes and heart disease were not significantly associated with dementia. A significant interaction was observed between APOE epsilon4 and stroke (P = 0.001).

CONCLUSIONS: Data from the first dementia study that is representative of the United States population suggest that stroke, the APOE epsilon4 allele and their interaction are strongly associated with dementia.

}, issn = {1758-9193}, doi = {10.1186/alzrt43}, url = {http://alzres.com/content/2/3/19}, author = {David J Llewellyn and Iain A Lang and Fiona E Matthews and Brenda L Plassman and Mary A M Rogers and Lewis B Morgenstern and Gwenith G Fisher and Mohammed U Kabeto and Kenneth M. Langa} } @article {7303, title = {Caregiving behavior is associated with decreased mortality risk.}, journal = {Psychol Sci}, volume = {20}, year = {2009}, month = {2009 Apr}, pages = {488-94}, publisher = {20}, abstract = {

Traditional investigations of caregiving link it to increased caregiver morbidity and mortality, but do not disentangle the effects of providing care from those of being continuously exposed to an ailing loved one with serious health problems. We explored this possible confound in a national, longitudinal survey of elderly married individuals (N= 3,376). Results showed that spending at least 14 hr per week providing care to a spouse predicted decreased mortality for the caregiver, independently of behavioral and cognitive limitations of the care recipient (spouse), and of other demographic and health variables. These findings suggest that it may be premature to conclude that health risks for caregivers are due to providing active help. Indeed, under some circumstances, caregivers may actually benefit from providing care.

}, keywords = {Altruism, Caregivers, Humans, Mortality}, issn = {1467-9280}, doi = {10.1111/j.1467-9280.2009.02323.x}, url = {http://pss.sagepub.com/content/20/4/4}, author = {Stephanie Brown and Dylan M Smith and Schulz, Richard and Mohammed U Kabeto and Peter A. Ubel and Poulin, Michael and Yi, Jaehee and Kim, Catherine and Kenneth M. Langa} } @article {7346, title = {Cognitive health among older adults in the United States and in England.}, journal = {BMC Geriatr}, volume = {9}, year = {2009}, note = {PMID: 19555494}, month = {2009 Jun 25}, pages = {23}, publisher = {9}, abstract = {

BACKGROUND: Cognitive function is a key determinant of independence and quality of life among older adults. Compared to adults in England, US adults have a greater prevalence of cardiovascular risk factors and disease that may lead to poorer cognitive function. We compared cognitive performance of older adults in the US and England, and sought to identify sociodemographic and medical factors associated with differences in cognitive function between the two countries.

METHODS: Data were from the 2002 waves of the US Health and Retirement Study (HRS) (n = 8,299) and the English Longitudinal Study of Ageing (ELSA) (n = 5,276), nationally representative population-based studies designed to facilitate direct comparisons of health, wealth, and well-being. There were differences in the administration of the HRS and ELSA surveys, including use of both telephone and in-person administration of the HRS compared to only in-person administration of the ELSA, and a significantly higher response rate for the HRS (87\% for the HRS vs. 67\% for the ELSA). In each country, we assessed cognitive performance in non-hispanic whites aged 65 and over using the same tests of memory and orientation (0 to 24 point scale).

RESULTS: US adults scored significantly better than English adults on the 24-point cognitive scale (unadjusted mean: 12.8 vs. 11.4, P < .001; age- and sex-adjusted: 13.2 vs. 11.7, P < .001). The US cognitive advantage was apparent even though US adults had a significantly higher prevalence of cardiovascular risk factors and disease. In a series of OLS regression analyses that controlled for a range of sociodemographic and medical factors, higher levels of education and wealth, and lower levels of depressive symptoms, accounted for some of the US cognitive advantage. US adults were also more likely to be taking medications for hypertension, and hypertension treatment was associated with significantly better cognitive function in the US, but not in England (P = .014 for treatment x country interaction).

CONCLUSION: Despite methodological differences in the administration of the surveys in the two countries, US adults aged >/= 65 appeared to be cognitively healthier than English adults, even though they had a higher burden of cardiovascular risk factors and disease. Given the growing number of older adults worldwide, future cross-national studies aimed at identifying the medical and social factors that might prevent or delay cognitive decline in older adults would make important and valuable contributions to public health.

}, keywords = {Aged, Aged, 80 and over, Aging, Cognition, Cognition Disorders, Cohort Studies, Cross-Sectional Studies, England, Female, Health Status, Humans, Longitudinal Studies, Male, Neuropsychological tests, United States}, issn = {1471-2318}, doi = {10.1186/1471-2318-9-23}, author = {Kenneth M. Langa and David J Llewellyn and Iain A Lang and David R Weir and Robert B Wallace and Mohammed U Kabeto and Felicia A Huppert} } @article {7413, title = {Cognitive performance and informant reports in the diagnosis of cognitive impairment and dementia in African Americans and whites.}, journal = {Alzheimers Dement}, volume = {5}, year = {2009}, month = {2009 Nov}, pages = {445-53}, publisher = {5}, abstract = {

BACKGROUND: The diagnosis of cognitive impairment and dementia must reflect an increasingly diverse and aging United States population. This study compared direct testing and informant reports of cognition with clinical diagnoses of cognitive impairment and dementia between African Americans and whites.

METHODS: Participants in the Aging, Demographics, and Memory Study completed in-person dementia evaluations, and were assigned clinical diagnoses (by a consensus panel of dementia experts) of normal; cognitive impairment, not demented (CIND); and dementia. The Consortium to Establish a Registry for Alzheimer{\textquoteright}s Disease (CERAD) total score and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were used to assess cognitive performance and reported cognitive decline.

RESULTS: A higher CERAD total score was associated with lower odds of CIND and dementia, at comparable ratios between African Americans and whites. Higher IQCODE scores were associated with increased odds of dementia in both African Americans and whites. Higher IQCODE scores were associated with increased odds of CIND among whites, but not among African Americans.

CONCLUSIONS: Cultural differences may influence informant reports of prevalent CIND and dementia. Our findings also highlight the need for more comparative research to establish the cultural validity of measures used to diagnose these conditions.

}, keywords = {Activities of Daily Living, Age of Onset, Aged, Aged, 80 and over, Black or African American, Caregivers, Cognition Disorders, Cohort Studies, Culture, Dementia, Disability Evaluation, Female, Geriatric Assessment, Health Surveys, Humans, Male, Neuropsychological tests, Observer Variation, Population Surveillance, Predictive Value of Tests, Prevalence, Psychiatric Status Rating Scales, Psychometrics, Registries, Sensitivity and Specificity, Surveys and Questionnaires, White People}, issn = {1552-5279}, doi = {10.1016/j.jalz.2009.04.1234}, author = {Guy G Potter and Brenda L Plassman and James R Burke and Mohammed U Kabeto and Kenneth M. Langa and David J Llewellyn and Mary A M Rogers and David C Steffens} } @article {7324, title = {Does caring for your spouse harm one{\textquoteright}s health? Evidence from a United States nationally-representative sample of older adults.}, journal = {Ageing Soc}, volume = {29}, year = {2009}, month = {2009 Feb}, pages = {277-293}, publisher = {29}, abstract = {

The purpose of this article is to investigate the relationship between spousal care-giving and declines in functioning and self-rated health among older care-givers. The authors used data from the 2000 and 2002 waves of the United States Health and Retirement Study, a biennial longitudinal survey of a nationally representative cohort of adults aged 50 or more years. Two outcomes were examined, declines in functioning and declines in self-rated health. Care-givers were classified into three groups: no care-giving, less than 14 hours of care-giving per week, and 14 or more hours care-giving per week. To assess declines in functioning, two summary scores were created of limitations in basic and instrumental Activities of Daily Living. To assess declines in self-rated health, we compared responses from 2000 and 2002. In the fully adjusted models, care-giving hours did not have an independent effect on declines in functioning or self-rated health. The relationship between care-giving hours and declines in functioning and self-rated health is probably attributable to socio-demographic characteristics, mainly age. The findings suggest that spousal care-giving does not of itself harm functional health or perceived health among older adult care-givers. Understanding the differential effects of these socio-economic characteristics with care-giving hours on health will be useful in promoting the health of older adult care-givers and treating their disorders.

}, issn = {0144-686X}, doi = {10.1017/S0144686X08007824}, author = {Kristi Rahrig Jenkins and Mohammed U Kabeto and Kenneth M. Langa} } @article {7311, title = {The effect of depression and cognitive impairment on enrollment in Medicare Part D.}, journal = {J Am Geriatr Soc}, volume = {57}, year = {2009}, month = {2009 Aug}, pages = {1433-40}, publisher = {57}, abstract = {

OBJECTIVES: To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage.

DESIGN: Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D.

SETTING: 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005.

PARTICIPANTS: Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents.

MEASUREMENTS: The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver.

RESULTS: Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D.

CONCLUSION: Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.

}, keywords = {Aged, Aged, 80 and over, Chi-Square Distribution, Cognition Disorders, depression, Female, Humans, Logistic Models, Longitudinal Studies, Male, Medicare Part D, Middle Aged, Patient Participation, Risk Factors, United States}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2009.02348.x}, author = {Zivin, Kara and Mohammed U Kabeto and Helen C Kales and Kenneth M. Langa} } @article {7367, title = {The influence of long-term care insurance on the likelihood of nursing home admission.}, journal = {J Am Geriatr Soc}, volume = {57}, year = {2009}, month = {2009 Oct}, pages = {1862-7}, publisher = {57}, abstract = {

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.

DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.

SETTING: Community-dwelling nationally representative sample.

PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.

METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.

RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2\%) possessed LTC insurance. A total of 1,778 (8.5\%) were admitted to a nursing home during the 8-year period: 149 (8.7\%) of those with LTC insurance and 1,629 (8.4\%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95\% confidence interval=0.83-1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.

CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.

}, keywords = {Aged, Aged, 80 and over, Female, Humans, Insurance, Long-Term Care, Longitudinal Studies, Male, Middle Aged, Nursing homes}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2009.02433.x}, author = {Tanya R Gure and Mohammed U Kabeto and Kenneth M. Langa} } @article {7316, title = {Parental education and late-life dementia in the United States.}, journal = {J Geriatr Psychiatry Neurol}, volume = {22}, year = {2009}, month = {2009 Mar}, pages = {71-80}, publisher = {22}, abstract = {

We investigated the relation between parental education and dementia in the United States. Participants in the Aging, Demographics, and Memory Study were included, with information regarding parental education obtained from the Health and Retirement Study. The odds of dementia in elderly Americans whose mothers had less then 8 years of schooling were twice (95\% CI, 1.1-3.8) that of individuals with higher maternal education, when adjusted for paternal education. Of elderly Americans with less educated mothers, 45.4\% (95\% CI, 37.4-53.4\%) were diagnosed with dementia or ;;cognitive impairment, no dementia{\textquoteright}{\textquoteright} compared to 31.2\% (95\% CI, 25.0-37.4\%) of elderly Americans whose mothers had at least an 8th grade education. The population attributable risk of dementia due to low maternal education was 18.8\% (95\% CI, 9.4-28.2\%). The education of girls in a population may be protective of dementia in the next generation.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Apolipoproteins E, Biomarkers, Cognition Disorders, Dementia, Educational Status, Fathers, Female, Genetic Predisposition to Disease, Humans, Longitudinal Studies, Male, Mothers, Odds Ratio, Parents, Prevalence, Prospective Studies, Racial Groups, Risk Factors, Sex Distribution, United States}, issn = {0891-9887}, doi = {10.1177/0891988708328220}, author = {Mary A M Rogers and Brenda L Plassman and Mohammed U Kabeto and Gwenith G Fisher and John J McArdle and David J Llewellyn and Guy G Potter and Kenneth M. Langa} } @article {7198, title = {Degree of disability and patterns of caregiving among older Americans with congestive heart failure.}, journal = {J Gen Intern Med}, volume = {23}, year = {2008}, month = {2008 Jan}, pages = {70-6}, publisher = {23}, abstract = {

OBJECTIVES: Although congestive heart failure (CHF) is a common condition, the extent of disability and caregiving needs for those with CHF are unclear. We sought to determine: (1) prevalence of physical disability and geriatric conditions, (2) whether CHF is independently associated with disability, (3) rates of nursing home admission, and (4) formal and informal in-home care received in the older CHF population.

METHODS: We used cross-sectional data from the 2000 wave of the Health and Retirement Study. We compared outcomes among three categories of older adults: (1) no coronary heart disease (CHD), (2) CHD, without CHF, and (3) CHF. Compared to those without CHF, respondents reporting CHF were more likely to be disabled (P < 0.001) and to have geriatric conditions (P < 0.001). Respondents reporting CHF were more likely to have been admitted to a nursing home (P < 0.05). CHF respondents were more functionally impaired than respondents without CHF.

RESULTS: The adjusted average weekly informal care hours for respondents reporting CHF was higher than for those reporting CHD but without CHF and those reporting no CHD (6.7 vs 4.1 vs 5.1, respectively; P < 0.05). Average weekly formal caregiving hours also differed among the three groups (1.3 CHF vs 0.9 CHD without CHF vs 0.7 no CHD; P > 0.05).

CONCLUSIONS: CHF imposes a significant burden on patients, families, and the long-term care system. Older adults with CHF have higher rates of disability, geriatric conditions, and nursing home admission.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Caregivers, Coronary Disease, Cross-Sectional Studies, Disabled Persons, Female, Health Surveys, Heart Failure, Hospitalization, Humans, Male, Nursing homes, United States}, issn = {1525-1497}, doi = {10.1007/s11606-007-0456-1}, author = {Tanya R Gure and Mohammed U Kabeto and Caroline S Blaum and Kenneth M. Langa} } @article {7272, title = {Trends in the prevalence and mortality of cognitive impairment in the United States: is there evidence of a compression of cognitive morbidity?}, journal = {Alzheimers Dement}, volume = {4}, year = {2008}, month = {2008 Mar}, pages = {134-44}, publisher = {4}, abstract = {

BACKGROUND: Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004.

METHODS: We used data from the Health and Retirement Study (HRS), a nationally representative population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the 1993 (N = 7,406) and 2002 (N = 7,104) waves of the HRS were included. CI was determined by using a 35-point cognitive scale for self-respondents and assessments of memory and judgment for respondents represented by a proxy. Mortality was ascertained with HRS data verified by the National Death Index.

RESULTS: In 1993, 12.2\% of those aged 70 or older had CI compared with 8.7\% in 2002 (P < .001). CI was associated with a significantly higher risk of 2-year mortality in both years. The risk of death for those with moderate/severe CI was greater in 2002 compared with 1993 (unadjusted hazard ratio, 4.12 in 2002 vs 3.36 in 1993; P = .08; age- and sex-adjusted hazard ratio, 3.11 in 2002 vs 2.53 in 1993; P = .09). Education was protective against CI, but among those with CI, more education was associated with higher 2-year mortality.

CONCLUSIONS: These findings support the hypothesis of a compression of cognitive morbidity between 1993 and 2004, with fewer older Americans reaching a threshold of significant CI and a more rapid decline to death among those who did. Societal investment in building and maintaining cognitive reserve through formal education in childhood and continued cognitive stimulation during work and leisure in adulthood might help limit the burden of dementia among the growing number of older adults worldwide.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Female, Humans, Male, Neurology, Prevalence, Quality of Life, Socioeconomic factors, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2008.01.001}, author = {Kenneth M. Langa and Eric B Larson and Jason H. Karlawish and David M Cutler and Mohammed U Kabeto and Scott Y H Kim and Allison B Rosen} } @article {7173, title = {Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients{\textquoteright} treatment priorities and self-management?}, journal = {J Gen Intern Med}, volume = {22}, year = {2007}, month = {2007 Dec}, pages = {1635-40}, publisher = {22}, abstract = {

BACKGROUND: The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40\% have at least three.

OBJECTIVE: We sought to understand how the number, type, and severity of comorbidities influence diabetes patients{\textquoteright} self-management and treatment priorities.

DESIGN: Cross-sectional observation study.

PATIENTS: A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.

MEASUREMENTS: We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).

RESULTS: 40\% of respondents had at least 1 microvascular comorbidity, 79\% at least 1 macrovascular comorbidity, and 61\% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.

CONCLUSIONS: The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients{\textquoteright} self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

}, keywords = {Aged, Attitude to Health, Cohort Studies, Comorbidity, Cross-Sectional Studies, Diabetes Mellitus, Female, Health Priorities, Heart Failure, Humans, Male, Middle Aged, Self Care, Severity of Illness Index, United States}, issn = {1525-1497}, doi = {10.1007/s11606-007-0313-2}, author = {Eve A Kerr and Michele M Heisler and Sarah L. Krein and Mohammed U Kabeto and Kenneth M. Langa and David R Weir and John D Piette} } @article {7158, title = {Geriatric conditions and disability: the Health and Retirement Study.}, journal = {Ann Intern Med}, volume = {147}, year = {2007}, month = {2007 Aug 07}, pages = {156-64}, publisher = {147}, abstract = {

BACKGROUND: Geriatric conditions, such as incontinence and falling, are not part of the traditional disease model of medicine and may be overlooked in the care of older adults. The prevalence of geriatric conditions and their effect on health and disability in older adults has not been investigated in population-based samples.

OBJECTIVE: To investigate the prevalence of geriatric conditions and their association with dependency in activities of daily living by using nationally representative data.

DESIGN: Cross-sectional analysis.

SETTING: Health and Retirement Study survey administered in 2000.

PARTICIPANTS: Adults age 65 years or older (n = 11 093, representing 34.5 million older Americans) living in the community and in nursing homes.

MEASUREMENTS: Geriatric conditions (cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment) and dependency in activities of daily living (bathing, dressing, eating, transferring, toileting).

RESULTS: Of adults age 65 years or older, 49.9\% had 1 or more geriatric conditions. Some conditions were as prevalent as common chronic diseases, such as heart disease and diabetes. The association between geriatric conditions and dependency in activities of daily living was strong and significant, even after adjustment for demographic characteristics and chronic diseases (adjusted risk ratio, 2.1 [95\% CI, 1.9 to 2.4] for 1 geriatric condition, 3.6 [CI, 3.1 to 4.1] for 2 conditions, and 6.6 [CI, 5.6 to 7.6] for > or =3 conditions).

LIMITATIONS: The study was cross-sectional and based on self-reported data. Because measures were limited by the survey questions, important conditions, such as delirium and frailty, were not assessed. Survival biases may influence the estimates.

CONCLUSIONS: Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care.

}, keywords = {Accidental Falls, Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Body Mass Index, Chronic disease, Cognition Disorders, Comorbidity, Cross-Sectional Studies, Disability Evaluation, Dizziness, Female, Geriatric Assessment, Geriatrics, Hearing Disorders, Humans, Male, Prevalence, Retirement, Urinary incontinence, Vision Disorders}, issn = {1539-3704}, doi = {10.7326/0003-4819-147-3-200708070-00004}, author = {Christine T Cigolle and Kenneth M. Langa and Mohammed U Kabeto and Zhiyi Tian and Caroline S Blaum} } @article {7140, title = {Informal caregiving and Body Mass Index among older adults.}, journal = {J Gerontol Nurs}, volume = {33}, year = {2007}, month = {2007 Apr}, pages = {42-51}, publisher = {33}, abstract = {

The authors sought to obtain nationally representative estimates of the time of informal caregiving provided to older adults classified into the four standard Body Mass Index (BMI) classifications. They estimated multivariate regression models using data from the 2000 Health and Retirement Study to determine the weekly hours of informal caregiving for older adults classified into the four standard BMI classifications. In the fully adjusted models, being underweight was associated with receiving significantly more informal care, however, obesity was not associated with more informal care. The implications of these findings are discussed in terms of nursing practice and research to prevent weight loss and frailty.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Body Mass Index, Body Weight, Caregivers, Female, Geriatric Assessment, Humans, Male, Social Class}, issn = {0098-9134}, doi = {10.3928/00989134-20070401-06}, author = {Kristi Rahrig Jenkins and Mohammed U Kabeto and Fultz, Nancy H. and Kenneth M. Langa} } @article {7048, title = {Differences in Amount of Informal Care Received by Non-Hispanic Whites and Latinos in a Nationally Representative Sample of Older Americans}, journal = {Journal of the American Geriatrics Society}, volume = {53}, year = {2005}, pages = {146-151}, publisher = {53}, abstract = {The objective of this study was to evaluate informal (unpaid) care and its broad determinants for Latinos in a nationally representative sample. A cross-sectional analysis of the 1993 Asset and Health Dynamics Study, a national probability sample of 7,443 older adults aged 70 and older, was performed to determine the independent effect of Latino ethnicity on the receipt of informal care by disabled older individuals. Self-reported race/ethnicity was used to predict the mean daily hours of informal care received for activity of daily living (ADL) or instrumental activity of daily living (IADL) assistance after adjustment for predisposing, need, and enabling variables. There was a significant association between informal home care and ethnic group, with 44.3 of Latinos receiving informal care, compared with 33.9 of African Americans and 24.6 of non-Hispanic whites (Po.001). After adjustment, Latinos received 11.0 weekly hours of informal care, compared with 7.5 hours for non-Hispanic whites and 6.3 hours for African Americans (Po.001). The results from this nationally representative sample indicate that Latinos receive significantly more hours of informal care on average than African Americans or non-Hispanic whites for ADL and IADL disability. Clinicians should be alert to the significant amount of informal care and possible associated strain in caregivers of older Latinos.}, keywords = {Healthcare, Women and Minorities}, author = {Weiss, Carlos O. and Hector M Gonz{\'a}lez and Mohammed U Kabeto and Kenneth M. Langa} } @article {7030, title = {Health, wealth, and happiness: financial resources buffer subjective well-being after the onset of a disability.}, journal = {Psychol Sci}, volume = {16}, year = {2005}, month = {2005 Sep}, pages = {663-6}, publisher = {16}, abstract = {

We examined the hypothesis that the relationship between financial status and subjective well-being, typically found to be very small in cross-sectional studies, is moderated by health status. Specifically, we predicted that wealth would buffer well-being after the onset of a disability. Using data from the Health and Retirement Study, a longitudinal study of people at and approaching retirement age, we employed within-subjects analyses to test whether wealth measured prior to the onset of a disability protected participants{\textquoteright} well-being from some of the negative effects of a new disability. We found support for this hypothesis: Participants who were above the median in total net worth reported a much smaller decline in well-being after a new disability than did participants who were below the median. We also found some evidence that the buffering effect of wealth faded with time, as below-median participants recovered some of their well-being.

}, keywords = {Activities of Daily Living, Cross-Sectional Studies, Disability Evaluation, Female, Follow-Up Studies, Happiness, Health Status, Humans, Male, Middle Aged, Quality of Life, Socioeconomic factors}, issn = {0956-7976}, doi = {10.1111/j.1467-9280.2005.01592.x}, author = {Dylan M Smith and Kenneth M. Langa and Mohammed U Kabeto and Peter A. Ubel} } @article {7019, title = {The impact of own and spouse{\textquoteright}s urinary incontinence on depressive symptoms.}, journal = {Soc Sci Med}, volume = {60}, year = {2005}, month = {2005 Jun}, pages = {2537-48}, publisher = {60}, abstract = {

This study investigated the impact of own and spouse{\textquoteright}s urinary incontinence on depressive symptoms. Attention was paid to the possibility that gender and caregiving might be important factors in understanding significant effects. We used negative binomial regression to analyze survey data for 9974 middle-aged and older respondents to the Health and Retirement Study in the USA. Results supported the hypothesis that the respondents{\textquoteright} own urinary incontinence was associated with depressive symptoms (unadj. IRR = 1.73, 95\% CIs = 1.53, 1.95 for men; unadj. IRR = 1.50, 95\% CIs = 1.38, 1.63 for women). Controlling sociodemographic and health variables reduced this relationship, but it remained statistically significant for both men and women. Having an incontinent wife put men at greater risk for depressive symptoms (unadj. IRR = 1.13, 95\% CIs = 1.02, 1.25), although this relation became nonsignificant with the addition of control variables. No relation between women{\textquoteright}s depressive symptoms and husbands{\textquoteright} (in)continence status was found. Caregiving was not a significant variable in the adjusted analyses, but spouses{\textquoteright} depressive symptoms emerged as a significant predictor of the respondents{\textquoteright} own depressive symptoms. Health care providers must be sensitive to the emotional impact of urinary incontinence. Our findings also suggest the importance of considering the patient{\textquoteright}s mental health within a wider context, particularly including the physical and mental health of the patient{\textquoteright}s spouse.

}, keywords = {Aged, Caregivers, Cohort Studies, depression, Female, Humans, Male, Middle Aged, United States, Urinary incontinence}, issn = {0277-9536}, doi = {10.1016/j.socscimed.2004.11.019}, author = {Fultz, Nancy H. and Kristi Rahrig Jenkins and Truls Ostbye and Donald H. Taylor Jr. and Mohammed U Kabeto and Kenneth M. Langa} } @article {7010, title = {Net worth predicts symptom burden at the end of life.}, journal = {J Palliat Med}, volume = {8}, year = {2005}, month = {2005 Aug}, pages = {827-37}, publisher = {8}, abstract = {

OBJECTIVES: To explore the predictors of symptom burden at the end of life.

DESIGN: Observational, secondary analysis of Health and Retirement Study (HRS) data.

SETTING: USA.

PARTICIPANTS: Two thousand six hundred four deceased, older adults.

METHODS: Multivariate Poisson and logistic regression to explore the relationship between sociodemographic and clinical factors with symptoms.

RESULTS: Fatigue, pain, dyspnea, depression, and anorexia were common and severe; 58\% of participants experienced more than 3 of these during their last year of life. Sociodemographic and clinical factors were associated with the number of symptoms as well as the presence of pain, depression, and dyspnea alone. Decedents in the highest quartile of net worth had fewer symptoms (incident rate ratio [IRR] 0.90, confidence interval [CI] 0.85-0.96) and less pain (odds ratio [OR] 0.66, CI 0.51-0.85) than comparisons did. Patients with cancer experienced more pain (OR 2.02, CI 1.62-2.53) and depression (OR 1.31, CI 1.07-1.61). Patients experienced more depression (OR 2.37, CI 1.85-3.03) and dyspnea (OR 1.40, CI 1.09-1.78).

LIMITATION: Use of proxy reports for primary data.

CONCLUSION: Older Americans experience a large symptom burden in the last year of life, largely with treatable symptoms such as pain, dyspnea, and depression. The adequacy of symptom control relates to clinical factors as well as net worth. This association between symptoms and wealth suggests that access to health care and other social services beyond those covered by Medicare may be important in decreasing symptom burden at the end of life.

}, keywords = {Aged, Aged, 80 and over, Data collection, Female, Humans, Logistic Models, Male, Severity of Illness Index, Social Class, Terminally Ill, United States}, issn = {1096-6218}, doi = {10.1089/jpm.2005.8.827}, author = {Maria J Silveira and Mohammed U Kabeto and Kenneth M. Langa} } @article {6991, title = {Setting eligibility criteria for a care-coordination benefit.}, journal = {J Am Geriatr Soc}, volume = {53}, year = {2005}, month = {2005 Dec}, pages = {2051-9}, publisher = {53}, abstract = {

OBJECTIVES: To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served.

DESIGN: Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older.

SETTING: Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey.

PARTICIPANTS: Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries).

MEASUREMENTS: Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency.

RESULTS: A small portion of Medicare beneficiaries (1.3-5.8\%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population.

CONCLUSION: Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Case Management, Chronic disease, Cognition Disorders, Comorbidity, Cross-Sectional Studies, Disability Evaluation, Disease Management, Eligibility Determination, Female, Geriatric Assessment, Health Surveys, Humans, Longitudinal Studies, Male, Medicare, Middle Aged, Retirement, United States}, issn = {0002-8614}, doi = {10.1111/j.1532-5415.2005.00496.x}, author = {Christine T Cigolle and Kenneth M. Langa and Mohammed U Kabeto and Caroline S Blaum} } @article {6918, title = {Extent and cost of informal caregiving for older Americans with symptoms of depression.}, journal = {Am J Psychiatry}, volume = {161}, year = {2004}, month = {2004 May}, pages = {857-63}, publisher = {161}, abstract = {

OBJECTIVE: The purpose of this study was to obtain nationally representative estimates of the additional time and cost associated with informal caregiving for older Americans with depressive symptoms.

METHOD: Data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people age 70 years or older (N=6,649), were used to determine the weekly hours and imputed costs of informal caregiving for elderly people with no depressive symptoms in the last week, one to three depressive symptoms in the last week, and four to eight depressive symptoms in the last week.

RESULTS: Forty-four percent of survey respondents reported one to three depressive symptoms, and 18\% reported four to eight depressive symptoms. In multivariate regression analyses that adjusted for sociodemographics, caregiver network, and coexisting chronic health conditions, respondents with no depressive symptoms received an average of 2.9 hours per week of informal care, compared with 4.3 hours per week for those with one to three symptoms and 6.0 hours per week for those with four to eight symptoms. Caregiving associated with depressive symptoms in elderly Americans represented a yearly cost of about $9 billion.

CONCLUSIONS: Depressive symptoms in elderly persons are independently associated with significantly higher levels of informal caregiving, even after the effects of major coexisting chronic conditions are adjusted. The additional hours of care attributable to depressive symptoms represent a significant time commitment for family members and, therefore, a significant societal economic cost. Further research should evaluate the causal pathways by which depressive symptoms lead to high levels of caregiving and should examine whether successful treatment of depression reduces the need for informal care.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Caregivers, Comorbidity, Costs and Cost Analysis, Depressive Disorder, Fees and Charges, Female, Health Care Costs, Home Nursing, Humans, Longitudinal Studies, Male, Personality Inventory, Workload}, issn = {0002-953X}, doi = {10.1176/appi.ajp.161.5.857}, author = {Kenneth M. Langa and Marcia A. Valenstein and A. Mark Fendrick and Mohammed U Kabeto and Sandeep Vijan} } @article {6920, title = {The health effects of restricting prescription medication use because of cost.}, journal = {Med Care}, volume = {42}, year = {2004}, note = {Comment in: Med Care. 2004 Jul;42(7):623-5 AN=15213485}, month = {2004 Jul}, pages = {626-34}, publisher = {42}, abstract = {

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS: In adjusted analyses, 32.1\% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2\% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9\% vs. 8.2\%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8\% vs. 5.3\%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

}, keywords = {Aged, Chronic disease, Female, Financing, Personal, Health Services Accessibility, Health Status, Humans, Male, Middle Aged, Multivariate Analysis, Patient Compliance, Prospective Studies, Risk, United States}, issn = {0025-7079}, doi = {10.1097/01.mlr.0000129352.36733.cc}, author = {Michele M Heisler and Kenneth M. Langa and Eby, Elizabeth L. and A. Mark Fendrick and Mohammed U Kabeto and John D Piette} } @article {6921, title = {Out-of-pocket health care expenditures among older Americans with dementia.}, journal = {Alzheimer Dis Assoc Disord}, volume = {18}, year = {2004}, month = {2004 Apr-Jun}, pages = {90-8}, publisher = {18}, abstract = {

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Costs and Cost Analysis, Data Interpretation, Statistical, Female, Financing, Personal, Health Care Costs, Health Expenditures, Health Surveys, Humans, Insurance Coverage, Longitudinal Studies, Male}, issn = {0893-0341}, doi = {10.1097/01.wad.0000126620.73791.3e}, author = {Kenneth M. Langa and Eric B Larson and Robert B Wallace and A. Mark Fendrick and Norman L Foster and Mohammed U Kabeto and David R Weir and Robert J. Willis and A. Regula Herzog} } @article {6914, title = {Out-of-pocket health-care expenditures among older Americans with cancer.}, journal = {Value Health}, volume = {7}, year = {2004}, month = {2004 Mar-Apr}, pages = {186-94}, publisher = {7}, abstract = {

OBJECTIVE: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS: Of the 6370 respondents, 5382 (84\%) reported No CA, 812 (13\%) reported CA/No Tx, and 176 (3\%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27\% of their yearly income on OOPE compared to only 5\% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

}, keywords = {Aged, Aged, 80 and over, Cost of Illness, Family Characteristics, Female, Financing, Personal, Health Expenditures, Health Services Research, Humans, Insurance, Health, Longitudinal Studies, Male, Medicaid, Medicare, Michigan, Neoplasms}, issn = {1098-3015}, doi = {10.1111/j.1524-4733.2004.72334.x}, author = {Kenneth M. Langa and A. Mark Fendrick and M.E. Chernew and Mohammed U Kabeto and Paisley, Kerry L. and Hayman, James A.} } @article {6919, title = {Predicting Nursing Home Admission: Estimates from a seven-year follow-up of a nationally representative sample of older Americans}, journal = {Alzheimer Disease and Associated Disorders}, volume = {18}, year = {2004}, pages = {83-89}, publisher = {18}, abstract = {This study determines whether prevalence and predictors of nursing home admission changed in the 1990s, during a period of dramatic changes in the service provision for and medical care of chronic impairments. Data from the 1993-2000 surveys of the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a longitudinal and nationally representative sample, were used. Proportional hazard models were used to determine the effects of dementia, physical functioning, clinical conditions, and sociodemographics on the likelihood of nursing home admission. Of the 6,676 respondents, 17 were admitted to a nursing home. Models excluding functional impairment demonstrated significant effects of chronic medical conditions and dementia on the risk of institutionalization. After controlling for functional impairment, dementia still had significant and strong effects on institutionalization but clinical conditions did not, suggesting that the impact of dementia goes beyond its effect on physical functioning. Nursing home admissions did not decrease during the study period, and the impact of dementia on the risk of nursing home admission did not decrease. Interventions for individuals with dementia should impact the behavioral aspects of the condition and slow disease progression in addition to improving physical functioning.}, keywords = {Demographics, Health Conditions and Status, Healthcare, Methodology}, author = {Banaszak-Holl, Jane and A. Mark Fendrick and Norman L Foster and A. Regula Herzog and Mohammed U Kabeto and Kent, David and Walter L. Straus and Kenneth M. Langa} } @article {6922, title = {Quality of preventive clinical services among caregivers in the health and retirement study.}, journal = {J Gen Intern Med}, volume = {19}, year = {2004}, month = {2004 Aug}, pages = {875-8}, publisher = {19}, abstract = {

We examined the association between caregiving for a spouse and preventive clinical services (self-reported influenza vaccination, cholesterol screening, mammography, Pap smear, and prostate cancer screening over 2 years and monthly self-breast exam) for the caregiver in a cross-sectional analysis of the Health and Retirement Study, a nationally representative sample of U.S. adults aged > or = 50 years (N = 11,394). Spouses engaged in 0, 1-14, or > or = 14 hours per week of caregiving. Each service was examined in logistic regression models adjusting for caregiver characteristics. After adjustment for covariates, there were no significant associations between spousal caregiving and likelihood of caregiver receipt of preventive services.

}, keywords = {Aged, Caregivers, Cohort Studies, Cross-Sectional Studies, Female, Health Care Surveys, Humans, Male, Middle Aged, Patient Acceptance of Health Care, Preventive Health Services, Quality of Health Care, Time Factors, United States}, issn = {0884-8734}, doi = {10.1111/j.1525-1497.2004.30411.x}, author = {Kim, Catherine and Mohammed U Kabeto and Robert B Wallace and Kenneth M. Langa} } @article {6790, title = {Informal caregiving for diabetes and diabetic complications among elderly americans.}, journal = {J Gerontol B Psychol Sci Soc Sci}, volume = {57}, year = {2002}, month = {2002 May}, pages = {S177-86}, publisher = {57B}, abstract = {

OBJECTIVES: Little is known regarding the amount of time spent by unpaid caregivers providing help to elderly individuals for disabilities associated with diabetes mellitus (DM). We sought to obtain nationally representative estimates of the time, and associated cost, of informal caregiving provided to elderly individuals with diabetes, and to determine the complications of DM that contribute most significantly to the subsequent need for informal care.

METHODS: We estimated multivariable regression models using data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people aged 70 or older (N = 7,443), to determine the weekly hours of informal caregiving and imputed cost of caregiver time for community-dwelling elderly individuals with and without a diagnosis of DM.

RESULTS: Those without DM received an average of 6.1 hr per week of informal care, those with DM taking no medications received 10.5 hr, those with DM taking oral medications received 10.1 hr, and those with DM taking insulin received 14.4 hr of care (p <.01). Disabilities related to heart disease, stroke, and visual impairment were important predictors of diabetes-related informal care. The total cost of informal caregiving for elderly individuals with diabetes in the United States was between $3 and $6 billion per year, similar to previous estimates of the annual paid long-term care costs attributable to DM.

DISCUSSION: Diabetes imposes a substantial burden on elderly individuals, their families, and society, both through increased rates of disability and the significant time that informal caregivers must spend helping address the associated functional limitations. Future evaluations of the costs of diabetes, and the cost-effectiveness of diabetes interventions, should consider the significant informal caregiving costs associated with the disease.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Cost of Illness, Costs and Cost Analysis, Diabetes Complications, Diabetes Mellitus, Disabled Persons, Female, Health Surveys, Humans, Hypoglycemic Agents, Insulin, Male, Time Factors}, issn = {1079-5014}, doi = {10.1093/geronb/57.3.s177}, author = {Kenneth M. Langa and Sandeep Vijan and Rodney A. Hayward and M.E. Chernew and Caroline S Blaum and Mohammed U Kabeto and David R Weir and Steven J. Katz and Robert J. Willis and A. Mark Fendrick} } @article {6791, title = {Informal caregiving time and costs for urinary incontinence in older individuals in the United States.}, journal = {J Am Geriatr Soc}, volume = {50}, year = {2002}, month = {2002 Apr}, pages = {733-7}, publisher = {50}, abstract = {

OBJECTIVES: To obtain nationally representative estimates of the additional time, and related cost, of informal caregiving associated with urinary incontinence in older individuals.

DESIGN: Multivariate regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people aged 70 and older (N = 7,443).

SETTING: Community-dwelling older people.

PARTICIPANTS: National population-based sample of community-dwelling older people.

MEASUREMENTS: Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling older people who reported (1) no unintended urine loss, (2) incontinence that did not require the use of absorbent pads, and (3) incontinence that required the use of absorbent pads.

RESULTS: Thirteen percent of men and 24\% of women reported incontinence. After adjusting for sociodemographics, living situation, and comorbidities, continent men received 7.4 hours per week of care, incontinent men who did not use pads received 11.3 hours, and incontinent men who used pads received 16.6 hours (P <.001). Women in these groups received 5.9, 7.6, and 10.7 hours (P <.001), respectively. The additional yearly cost of informal care associated with incontinence was $1,700 and $4,000 for incontinent men who did not and did use pads, respectively, whereas, for women in these groups, the additional yearly cost was $700 and $2,000. Overall, this represents a national annual cost of more than $6 billion for incontinence-related informal care.

CONCLUSIONS: The quantity of informal caregiving for older people with incontinence and its associated economic cost are substantial. Future analyses of the costs of incontinence, and the cost-effectiveness of interventions to prevent or treat incontinence, should consider the significant informal caregiving costs associated with this condition.

}, keywords = {Aged, Caregivers, Comorbidity, Confounding Factors, Epidemiologic, Female, Humans, Incontinence Pads, Male, Regression Analysis, Time Factors, United States, Urinary incontinence}, issn = {0002-8614}, doi = {10.1046/j.1532-5415.2002.50170.x}, author = {Kenneth M. Langa and Fultz, Nancy H. and Sanjay Saint and Mohammed U Kabeto and A. Regula Herzog} } @article {6793, title = {A national study of the quantity and cost of informal caregiving for the elderly with stroke.}, journal = {Neurology}, volume = {58}, year = {2002}, month = {2002 Jun 25}, pages = {1754-9}, publisher = {58}, abstract = {

BACKGROUND: As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.

OBJECTIVE: To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.

METHODS: The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.

RESULTS: Of 7,443 respondents, 656 (8.8\%) reported a history of stroke. Of those, 375 (57\%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke +/- SRHP (p < 0.01). Using the median 1999 home health aide wage (8.20 dollars/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from 3,500 dollars to 8,200 dollars. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to 6.1 billion dollars for stroke-related informal caregiving in the United States.

CONCLUSIONS: Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Confidence Intervals, Female, Humans, Longitudinal Studies, Male, Multivariate Analysis, Stroke, United States}, issn = {0028-3878}, doi = {10.1212/wnl.58.12.1754}, author = {Hickenbottom, S.L. and A. Mark Fendrick and Kutcher, J.S. and Mohammed U Kabeto and Steven J. Katz and Kenneth M. Langa} } @article {6742, title = {Estimating the cost of informal caregiving for elderly patients with cancer.}, journal = {J Clin Oncol}, volume = {19}, year = {2001}, month = {2001 Jul 01}, pages = {3219-25}, publisher = {19}, abstract = {

PURPOSE: As the United States population ages, the increasing prevalence of cancer is likely to result in higher direct medical and nonmedical costs. Although estimates of the associated direct medical costs exist, very little information is available regarding the prevalence, time, and cost associated with informal caregiving for elderly cancer patients.

MATERIALS AND METHODS: To estimate these costs, we used data from the first wave (1993) of the Asset and Health Dynamics (AHEAD) Study, a nationally representative longitudinal survey of people aged 70 or older. Using a multivariable, two-part regression model to control for differences in health and functional status, social support, and sociodemographics, we estimated the probability of receiving informal care, the average weekly number of caregiving hours, and the average annual caregiving cost per case (assuming an average hourly wage of $8.17) for subjects who reported no history of cancer (NC), having a diagnosis of cancer but not receiving treatment for their cancer in the last year (CNT), and having a diagnosis of cancer and receiving treatment in the last year (CT).

RESULTS: Of the 7,443 subjects surveyed, 6,422 (86\%) reported NC, 718 (10\%) reported CNT, and 303 (4\%) reported CT. Whereas the adjusted probability of informal caregiving for those respondents reporting NC and CNT was 26\%, it was 34\% for those reporting CT (P <.05). Those subjects reporting CT received an average of 10.0 hours of informal caregiving per week, as compared with 6.9 and 6.8 hours for those who reported NC and CNT, respectively (P <.05). Accordingly, cancer treatment was associated with an incremental increase of 3.1 hours per week, which translates into an additional average yearly cost of $1,200 per patient and just over $1 billion nationally.

CONCLUSION: Informal caregiving costs are substantial and should be considered when estimating the cost of cancer treatment in the elderly.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Caregivers, Cost of Illness, Family, Female, Home Nursing, Humans, Male, Multivariate Analysis, Neoplasms, Regression Analysis, United States}, issn = {0732-183X}, doi = {10.1200/JCO.2001.19.13.3219}, author = {Hayman, James A. and Kenneth M. Langa and Mohammed U Kabeto and Steven J. Katz and DeMonner, Sonya M. and M.E. Chernew and Slavin, Mitchell B. and A. Mark Fendrick} } @article {6726, title = {The explosion in paid home health care in the 1990s: who received the additional services?}, journal = {Med Care}, volume = {39}, year = {2001}, month = {2001 Feb}, pages = {147-57}, publisher = {39}, abstract = {

OBJECTIVE: Public expenditures for home health care grew rapidly in the 1990s, but it remains unclear to whom the additional services were targeted. This study tests whether the rapidly increasing expenditures were targeted to the elderly with high levels of disability and low levels of social support, 2 groups that have historically been higher users of paid home health and nursing home services.

METHODS: The Asset and Health Dynamics Study, a nationally representative, longitudinal survey of people > or = 70 years of age (n = 7,443), was used to determine the association of level of disability and level of social support with the use of paid home care services in both 1993 and 1995. Multivariable regression models were used to adjust for sociodemographics, recent hospital or nursing home admissions, chronic medical conditions, and receipt of informal care from family members.

RESULTS: Those with higher levels of disability received more adjusted weekly hours of paid home care in both 1993 and 1995. In 1993, users of paid home care with the least social support (unmarried living alone) received more adjusted weekly hours of care than the unmarried elderly living with others (24 versus 13 hours, P < 0.01) and the married (24 versus 18 hours, P = 0.06). However, by 1995, those who were unmarried and living with others were receiving the most paid home care: 40 versus 26 hours for the unmarried living alone (P < 0.05) and 24 hours for the married (P < 0.05).

CONCLUSIONS: The recent large increase in formal home care services went disproportionately to those with greater social support. Home care policy changes in the early 1990s resulted in a shift in the distribution of home care services toward the elderly living with their children.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Chronic disease, Family Characteristics, Female, Financing, Government, Frail Elderly, Geriatric Assessment, Health Care Surveys, Health Expenditures, health policy, Home Care Services, Home Nursing, Humans, Longitudinal Studies, Male, Marital Status, Multivariate Analysis, Social Support, Socioeconomic factors, Surveys and Questionnaires, United States, Utilization Review}, issn = {0025-7079}, doi = {10.1097/00005650-200102000-00005}, author = {Kenneth M. Langa and M.E. Chernew and Mohammed U Kabeto and Steven J. Katz} } @article {6738, title = {National estimates of the quantity and cost of informal caregiving for the elderly with dementia.}, journal = {J Gen Intern Med}, volume = {16}, year = {2001}, month = {2001 Nov}, pages = {770-8}, publisher = {16}, abstract = {

OBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443).

SETTING: National population-based sample of the community-dwelling elderly.

MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status.

RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars.

CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

}, keywords = {Aged, Aged, 80 and over, Caregivers, Cost of Illness, Dementia, Female, Health Care Costs, Humans, Male, Multivariate Analysis, Regression Analysis, Severity of Illness Index, Time Factors, United States}, issn = {0884-8734}, doi = {10.1111/j.1525-1497.2001.10123.x}, author = {Kenneth M. Langa and M.E. Chernew and Mohammed U Kabeto and A. Regula Herzog and Mary Beth Ofstedal and Robert J. Willis and Robert B Wallace and Mucha, L.M. and Walter L. Straus and A. Mark Fendrick} } @article {6699, title = {Gender disparities in the receipt of home care for elderly people with disability in the United States.}, journal = {JAMA}, volume = {284}, year = {2000}, month = {2000 Dec 20}, pages = {3022-7}, publisher = {284}, abstract = {

CONTEXT: Projected demographic shifts in the US population over the next 50 years will cause families, health care practitioners, and policymakers to confront a marked increase in the number of people with disabilities living in the community. Concerns about the adequacy of community support are particularly salient to women, who make up a disproportionate number of disabled elderly people and who may be particularly vulnerable because they are more likely to live alone with limited financial resources.

OBJECTIVE: To address gender differences in receipt of informal and formal home care.

DESIGN, SETTING, AND PARTICIPANTS: Nationally representative survey conducted in 1993 among 7443 noninstitutionalized people (4538 women and 2905 men) aged 70 years or older.

MAIN OUTCOME MEASURE: Number of hours per week of informal (generally unpaid) and formal (generally paid) home care received by survey participants who reported any activity of daily living (ADL) or instrumental activity of daily living (IADL) impairment (n = 3109) compared by gender and living arrangement and controlling for other factors.

RESULTS: Compared with disabled men, disabled women were much more likely to be living alone (45.4\% vs 16.8\%, P<.001) and much less likely to be living with a spouse (27.8\% vs 73.6\%, P<.001). Overall, women received fewer hours of informal care per week than men (15.7 hours; 95\% confidence interval [CI], 14.5-16.9 vs 21.2 hours; 95\% CI, 19. 7-22.8). Married disabled women received many fewer hours per week of informal home care than married disabled men (14.8 hours; 95\% CI, 13.7-15.8 vs 26.2 hours; 95\% CI, 24.6-27.9). Children (>80\% women) were the dominant caregivers for disabled women while wives were the dominant caregivers of disabled men. Gender differences in formal home care were small (2.8 hours for women; 95\% CI, 2.5-3.1 vs 2.1 hours for men; 95\% CI, 1.7-2.4).

CONCLUSION: Large gender disparities appear to exist in the receipt of informal home care for disabled elderly people in the United States, even within married households. Programs providing home care support for disabled elderly people need to consider these large gender disparities and the burden they impose on families when developing intervention strategies in the community.

}, keywords = {Activities of Daily Living, Aged, Disabled Persons, Family, Female, Geriatrics, Home Care Services, Home Nursing, Humans, Male, Regression Analysis, Sex Distribution, United States}, issn = {0098-7484}, doi = {10.1001/jama.284.23.3022}, author = {Steven J. Katz and Mohammed U Kabeto and Kenneth M. Langa} }